A countrywide point prevalence study in South Africa – using technology to determine use and appropriateness

Background: Antimicrobial resistance (AMR) is a serious world-wide health concern and a direct threat to future patient safety, with the misuse and overuse of antimicrobials increasing AMR rates. Consequently, it is imperative to measure current antibiotic utilisation within hospitals to guide future quality initiatives. However, data on antimicrobial utilization among public hospitals and primary health care centres (PHCs) in South Africa (SA) is currently lacking and needs to be addressed. Objectives: To describe and quantify how AMs are currently utilised in selected public sector hospitals and PHC centres in SA; to determine how mHealth techniques can be used to monitor AM utilisation in selected public sector hospitals and PHC centres in SA; to assess current programmes among public sector hospitals and PHC centres to improve AM prescribing as part of AMSPs and pharmacy and therapeutics committee (PTC) activities; to develop interventions, including mHealth techniques, to enhance the role and activities of AMSPs and PTCs; to measure prescriber compliance to STGs for ID in public sector hospitals and PHC centres in SA; to develop interventions, including mHealth techniques, to monitor and enhance prescribing compliance to STGs; to determine the utilisation, uptake and timeliness of vaccines (EPI and seasonal influenza) in selected public and private sector facilities across SA, as part of an AMS strategy to reduce AMR; finally, to develop interventions, including mHealth techniques, that can be used to enhance the appropriate use of vaccines in selected public and private sector facilities across SA. Methods: A web-based application tool was developed in South Africa based on previous PPS studies conducted in Botswana and South Africa using paper-based collection tools,and evaluated during July 2017. Key variables measured included antimicrobial utilisation patterns and appropriateness of treatment for sepsis in the Intensive Care Units (ICUs) and paediatric diarrhea in the CHCs Results: Preliminary results will include data from three provinces with 2455 patient files reviewed with all of their antimicrobial therapy and related results Conclusions: The PPS method offers a standardized tool that can be used to identify targets for quality improvement programmes in hospitals. The development of a web-based application (APP) has allowed the team to collect large datasets throughout Southern Africa

Feasibility of using point prevalence surveys to assess antimicrobial utilisation in public hospitals in South Africa : a pilot study and implications

OBJECTIVES: There is currently a lack of data regarding antimicrobial use among public hospitals in South Africa. This is a concern given their growing use and increasing antimicrobial resistance rates in South Africa. Consequently, the objectives of this study were to firstly determine the appropriateness of point prevalence survey (PPS) data collection instruments for performing antimicrobial utilization studies among public sector hospitals in South Africa; secondly, to determine current antimicrobial utilization in a public sector hospital, and thirdly evaluate the prescribing of antimicrobials with those contained within the national Essential Medicines List and Standard Treatment Guidelines (EML/STGs). The findings will be used to guide future activities in South Africa. METHODS: A PPS was conducted in Dr George Mukhari Academic Hospital. For each in-patient ward, all patients' files were completely surveyed on a single day. The number of patients who were on antimicrobials served as the numerator and the denominator comprised the total number of patients in the ward. RESULTS: 39 wards and 512 patient files were surveyed. The overall prevalence of antimicrobial use was 37.7%, highest in the ICUs. Beta lactamase inhibitors and antimicrobials for tuberculosis were the most prevalent antimicrobials. More than two thirds (83%) of antimicrobial treatment was modified following culture sensitivity test results when requested, and 98% of antimicrobials prescribed were contained within the current EML/STGs. In 10.8% of occasions, antimicrobials appear to have been prescribed other than for treatment, i.e. no systemic infection. There were concerns though with the lack of IV to oral switching. CONCLUSION: The PPS method offers a standardized tool that can be used to identify targets for quality improvement. However, there were concerns with the time taken to conduct PPS studies, which is an issue in resource limited settings. This is being addressed alongside concerns with the lack of IV to oral switching

Ongoing Initiatives to Improve the Quality and Efficiency of Medicine Use within the Public Healthcare System in South Africa; A Preliminary Study

Introduction: South Africa has an appreciable burden of both communicable and non-communicable diseases as well as high maternal, neonatal, and child morbidity. In recent years there have been significant strides with improving the public health system, and addressing current inequalities, with the right to health a constitutional provision in South Africa. Initiatives include the introduction of National Health Insurance, programmes to enhance access to medicines for patients with chronic diseases, as well as activities to improve care in hospitals, including improving pharmacovigilance. Consequently, the objective of this paper is to review ongoing initiatives within the public healthcare sector in South Africa and their influence to provide future direction.Method: Principally a structured review of current and planned activities.Results: There have been a number of major activities and initiatives surrounding the availability and access to medicines in the public system in recent years in South Africa. This includes a National Surveillance Centre and an innovative early warning system for the supply of medicines as well as the development of a National Health Care Pricing Authority and initiatives to improve contracting. There have also been developments to improve the supply chain including instigating Medicine Procurement Units in the provinces and enhancing forecasting capabilities. Access to medicines is improving though the instigation of stable chronic disease management initiatives to increase the number of external pick-up points for medicines. There are also ongoing programmes to enhance adherence to medicines as well as enhance adherence to the Standard Treatment Guidelines and the Essential Medicines List with their increasing availability. In addition, there is a movement to enhance the role of health technology assessment in future decision making. Hospital initiatives include increased focus on reducing antimicrobial resistance through instigating stewardship programmes as well as improving adverse drug reaction reporting and associated activities.Conclusion: Overall, there are an appreciable number of ongoing activities within the public healthcare system in South Africa attempting to ensure and sustain universal healthcare. It is too early to assess their impact, which will be the subject of future research

Web-based point prevalence survey of antimicrobial use and quality indicators at Raleigh Fitkin Memorial Hospital in Eswatini and the implications

Background: Eswatini is located in Sub-Saharan Africa. There is limited knowledge regarding antimicrobial utilisation among public hospitals across Africa, which is a challenge with rising antimicrobial resistance rates. Objective: To undertake a point prevalence survey (PPS) at Raleigh Fitkin Memorial (RFM) Hospital, the leading regional hospital in Eswatini with the findings driving future programmes. Method: PPS was undertaken at RFM using the Knack web-based application (App) to speed-up data collection, with antimicrobials categorised according to the World Health Organization Access, Watch, and Reserve classification. Each ward was surveyed in one day using patient files. Results: Overall, 68 patient files in 12 wards were surveyed; 88.2% (60/68) received at least one antimicrobial. Prescribed antimicrobials were mainly from the Access group (69.9%), none from the Reserve group. Amoxicillin (24.5%) and ceftriaxone IV (21.6%) were the most prescribed antibiotics. Of concern was that antibiotics were prescribed empirically for all patients (100%) with most administered IV (88.3%; 91/103). In addition, there was no documented switch or stop dates for administered antibiotics or any patient culture or drug sensitivity results recorded. Alongside this, extended courses of antimicrobials were typically administered as part of prophylaxis for surgical patients (80%; 12/15) despite concerns. Conclusion: There were considerable concerns with current antimicrobial use. Identified targets included reducing extended administration for surgical prophylaxis, encouraging earlier switching to oral antimicrobials and undertaking sensitivity testing. In addition, routinely documenting stop dates. The App appreciably reduced data collection times and analysis, and could potentially be used in other low- and middle-income countries

Compliance with South Africa's antimicrobial resistance national strategy framework : are we there yet?

Antimicrobial resistance (AMR) is a growing problem worldwide. South Africa has recently released its Antimicrobial Resistance National Strategy Framework (referred to as the Framework) to instigate antimicrobial stewardship programmes (ASPs). Consequently, there is a need to assess compliance with the Framework. Methods: Descriptive study design, collecting quantitative data, among pre-selected public healthcare facilities. One healthcare professional from each participating facility, involved in ASPs, was invited to participate. Results: Overall 26 facilities from 8 provinces participated. Average compliance to the Framework was 59.5% for the 26 facilities, with 38.0% for community health centres, 66.9% for referral hospitals and 73.5% for national central hospitals. For 7 facilities compliance was 80% compliant. Conclusion: Although some facilities complied well with the Framework, overall compliance was sub-optimal. With the introduction of universal healthcare in South Africa, coupled with growing AMR rates, ongoing initiatives to actively implement the Framework should be targeted at non-compliant facilities

SASOCP position statement on the pharmacist’s role in antibiotic stewardship 2018

Antibiotics are the most commonly prescribed medicines in global healthcare practice today. Their effectiveness is crucial and often life-saving in humanity’s battle against pathogens and infectious diseases. Antibiotic/antimicrobial stewardship strategies and programmes have become vital to the preservation of effective antibiotics and the optimisation of their use. The South African Society of Clinical Pharmacy (SASOCP) has written this guideline to outline the importance, role and purpose of pharmacists in such stewardship programmes, both in the public, as well as the private hospital sectors in South Africa. It also provides an overview of various approaches to antibiotic preservation, behavioural change, stewardship measures, and monitoring strategies

Compliance to the primary health care treatment guidelines and the essential medicines list in the management of sexually transmitted infections in correctional centres in South Africa : findings and implications

Background: The emergence of antimicrobial resistance (AMR) is a global concern and a growing health crisis. Additionally, evidence has shown that non-compliance to treatment guidelines, especially in the management of communicable diseases such as sexually transmitted infections (STIs), has the potential of further enhancing AMR rates. Data on the extent of these challenges in Primary Health Care (PHC) facilities in correctional centres in South Africa (SA) is limited. Hence this study was conducted to determine the level of compliance with the 2008 PHC Standard Treatment Guidelines and Essential Medicines List (PHC STGs/EML) in the management of STIs, and to identify potential factors contributing to the compliance and non-compliance to guide future strategies. Method: An investigational descriptive study, including retrospective and prospective data, was conducted over an eight month period. Results: Male urethritis syndrome, lower abdominal pain and genital ulcer syndrome were the three most common STIs. Doxycycline, ciprofloxacin and metronidazole were prescribed for most of the STIs. Overall compliance to the 2008 PHC STGs/EML was low for all STIs. Conclusion: The study highlights the need to implement antimicrobial stewardship programmes, including educational activities, to promote the rational use of antimicrobials and monitor their use in PHCs in SA

A narrative review of antibiotic prescribing practices in primary care settings in South Africa and potential ways forward to reduce antimicrobial resistance

DATA AVAILABILITY STATEMENT : We have already referenced all sourced papers and publications.SUPPLEMENTARY MATERIALS : TABLE S1. Suggested activities in the short to medium term to reduce inappropriate prescribing of antibiotics in primary care settings in South Africa; TABLE S2: ASPs introduced across LMICs to improve antimicrobial prescribing in ambulatory settings and their impact. References [155–170] are cited in the supplementary materials.There are concerns with the current prescribing of antibiotics in both the private and public primary care settings in South Africa. These concerns need to be addressed going forward to reduce rising antimicrobial resistance (AMR) rates in South Africa. Concerns include adherence to current prescribing guidelines. Consequently, there is a need to comprehensively summarise current antibiotic utilization patterns from published studies as well as potential activities to improve prescribing, including indicators and antimicrobial stewardship programs (ASPs). Published studies showed that there was an appreciable prescribing of antibiotics for patients with acute respiratory infections, i.e., 52.9% to 78% or more across the sectors. However, this was not universal, with appreciable adherence to prescribing guidelines in community health centres. Encouragingly, the majority of antibiotics prescribed, albeit often inappropriately, were from the ‘Access’ group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than ‘Watch’ antibiotics to limit AMR. Inappropriate prescribing of antibiotics in primary care is not helped by concerns with current knowledge regarding antibiotics, AMR and ASPs among prescribers and patients in primary care. This needs to be addressed going forward. However, studies have shown it is crucial for prescribers to use a language that patients understand when discussing key aspects to enhance appropriate antibiotic use. Recommended activities for the future include improved education for all groups as well as regularly monitoring prescribing against agreed-upon guidelines and indicators.https://www.mdpi.com/journal/antibioticsam2024PharmacologySDG-03:Good heatlh and well-bein

A narrative review of antibiotic prescribing practices in primary care settings in South Africa and potential ways forward to reduce antimicrobial resistance

There are concerns with the current prescribing of antibiotics in both the private and public primary care settings in South Africa. These concerns need to be addressed going forward to reduce rising antimicrobial resistance (AMR) rates in South Africa. Concerns include adherence to current prescribing guidelines. Consequently, there is a need to comprehensively summarise current antibiotic utilization patterns from published studies as well as potential activities to improve prescribing, including indicators and antimicrobial stewardship programs (ASPs). Published studies showed that there was an appreciable prescribing of antibiotics for patients with acute respiratory infections, i.e., 52.9% to 78% or more across the sectors. However, this was not universal, with appreciable adherence to prescribing guidelines in community health centres. Encouragingly, the majority of antibiotics prescribed, albeit often inappropriately, were from the ‘Access’ group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than ‘Watch’ antibiotics to limit AMR. Inappropriate prescribing of antibiotics in primary care is not helped by concerns with current knowledge regarding antibiotics, AMR and ASPs among prescribers and patients in primary care. This needs to be addressed going forward. However, studies have shown it is crucial for prescribers to use a language that patients understand when discussing key aspects to enhance appropriate antibiotic use. Recommended activities for the future include improved education for all groups as well as regularly monitoring prescribing against agreed-upon guidelines and indicators